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10.31.2013

Guest post: A view from Kampala, Uganda

This post is from Dr. Anne Dougherty, MD. She is almost in the middle of a six-week project at Mulago Hospital in Kampala where she is providing support and training to the OB/GYN staff. I will let her words speak for themselves.

Resigned helplessness – that is what the resident’s face said as she
answered questions following her presentation. The patient was a young
woman who was transferred from an outside hospital for “confusion and
severe anemia.” On arrival at Mulago, the patient was tachycardic and
tachypneic. Her mental status was altered. Her abdomen was distended
and rigid. She was bleeding per vagina. A pregnancy test was
performed and was positive. My assumption at this point is that the
patient has a ruptured ectopic pregnancy and is in danger of bleeding to
death. An IV was placed and normal saline was dripping into her vein.
No additional labs or studies were obtained. This all happened at 1AM. At 9AM
– eight hours later, the resident stood before the department at
morning meeting and related this story. There was no more to the story
than what I just told you. For the last eight hours, the patient had
lain in a bed on the ward where a single nurse watched over 40-50
patients with a single IV running crystalloid @ 125cc/hour. The
resident was asked, what did the ultrasound show? Did you locate the
pregnancy? What was causing the surgical abdomen? Did you draw
coagulation studies? I was struck that in the telling of the story, the
resident did not mention that these might be things that she
considered. When asked why such studies were not obtained, she simply
stated that it was 1AM.
As if the main referral hospital in the country should close at a
certain hour. Well, as it turns out, it does or at least that is the
perception that then becomes a reality.

A horrible inhumane experiment was performed with dogs in which they
were placed in a cage with an electrified floor. There was a high
barrier in the cage over which the dogs could not jump. The first few
times the floor was electrified, the dogs tried desperately to get over
the barrier, but as time went on, they would curl up in the corner until
it was over. The dogs continued to do this although the barrier was
lowered such that the dog could jump over it. This is not to say that
humans are dogs, but it does demonstrate the effect of repeated negative
events on the desire to keep trying, to keep striving.

I have seen repeatedly that when even a small challenge is presented
here at Mulago, the answer is often, “it is impossible.” And yet I know
that it cannot be as I see some are able to overcome the challenges.
Today, while performing a series of exams on patients with suspected
cervical cancer, I ran out of exam gloves. I asked the “sister” (that
is what the nurses are called) if she could get more gloves. She said,
we do not have any more and just stared at me. She said the person who
was supposed to go to the supply annex last night to restock did not
turn up and so we were low on supplies. Not being one to take no for an
answer, I persisted. Well, I said, where can we get them from now?
She said, give me a minute. In a short time, the “sister” returned
with a new box of gloves “borrowed” from another unit.

One of the things about cultural exchange is that you really have to
leave yourself at home. That is, you need to surrender your sense that
“this is the way things have to be done.” As long as you continue to
compare here to there, it is easy to be irritated by the way things
proceed within the foreign culture and ultimately become very
frustrated. And in that frustration you miss the cultural exchange. In
medicine that can sometimes be difficult. When you have a patient in
front of you who could be helped with a few basic diagnostic tests and
swifter treatment, I feel another force at work that is complicated to
separate from my own cultural context. The feeling of responsibility I
have to the patient while embedded in my cultural context feels like it
stems from an inner part of my being and is so painful to let go even
temporarily. And yet, that is really what you have to do here at Mulago
or you will be crushed by the tragedy of it.

I am not sure that I understand entirely where the resigned helplessness
comes from. It is likely multifactorial. Being subjected as a
colonial territory plays a part. Follow that with decades of struggle
and war while surrounding countries began to get their independent
“legs” under them. Add in poverty, food scarcity, unemployment,
resource shortages and a dejected passivity develops. I am also quite
sure that western world “charity” contributes. Interestingly though,
when you learn the stories behind some of these Ugandans and the life
challenges that they have overcome, you are left with paradox. Ne
woman told a story of moving out of her stepfather’s house because he
would beat her mother when she showed affection to the woman and her
sister. She moved in with a relative who took her on as household help
(a common practice here), but the woman wanted to go to school. So she
moved onto the streets where she tried to earn some money during the day
to support her sister and herself and then went to primary school as an
adult. She taught herself English while living on the streets. As a
cleaner at Mulago Hospital, someone discovered that she spoke English
and promoted her. She worked her way to a stable job as an
administrative assistant. She continues to go to school and is now
married, expecting a baby shortly. Amazing. And her story is only one
of many. So many Ugandans have witnessed horrendous violence either at
home or at the hands of the government. Most have been in a home
without enough food to feed the whole family. Many have inherited
entire families of 6, 7, 8 children when parents pass away from HIV
related illnesses. They will work against all odds to send those
children through school. The strength and wherewithal to persevere
through such trials is more than the average American in 2013 would
tolerate I think. And yet that same woman might tell you there are no
more gloves. Such a strange paradox.